Chapter 16

But first, there are a number of terms which we are in the habit of using in a vague though not unintelligible way, and which it is as well now to define. These terms are the tools with which we are to work, and the first thing is to sharpen them. It is nothing to us that they have been sharpened a thousand times before; they always get dull in the using, and every new workman has a right to carry them to the grindstone and sharpen them to suit himself.

Nature, in medical language, as opposed to Art, means trust in the reactions of the living system against ordinary normal impressions.

Art, in the same language, as opposed to Nature, means an intentional resort to extraordinary abnormal impressions for the relief of disease.

The reaction of the living system is the essence of both. Food is nothing, if there is no digestive act to respond to it. We cannot raise a blister on a dead man, or hope that a carminative forced between his lips will produce its ordinary happy effect.

Disease, dis-ease,--disturbed quiet, uncomfortableness,--means imperfect or abnormal reaction of the living system, and its more or less permanent results.

Food, in its largest sense, is whatever helps to build up the normal structures, or to maintain their natural actions.

Medicine, in distinction from food, is every unnatural or noxious agent applied for the relief of disease.

Physic means properly the Natural art, and Physician is only the Greek synonyme of Naturalist.

With these few explanations I proceed to unfold the propositions I have mentioned.

Disease and death, if we may judge by the records of creation, are inherently and essentially necessary in the present order of things. A perfect intelligence, trained by a perfect education, could do no more than keep the laws of the physical and spiritual universe. An imperfect intelligence, imperfectly taught,--and this is the condition of our finite humanity,--will certainly fail to keep all these laws perfectly. Disease is one of the penalties of one of the forms of such failure. It is prefigured in the perturbations of the planets, in the disintegration of the elemental masses; it has left its traces in the fossil organisms of extinct creations. [Professor Agassiz has kindly handed me the following note: “There are abnormal structures in animals of all ages anterior to the creation of mankind. Malformed specimens of Crinoids are known from the Triassic and Jurassic deposits. Malformed and diseased bones of tertiary mammalia have been collected in the caverns of Gailenreuth with traces of healing.”]

But it is especially the prerogative, I had almost said privilege, of educated and domesticated beings, from man down to the potato, serving to teach them, and such as train them, the laws of life, and to get rid of those who will not mind or cannot be kept subject to these laws.

Disease, being always an effect, is always in exact proportion to the sum of its causes, as much in the case of Spigelius, who dies of a scratch, as in that of the man who recovers after an iron bar has been shot through his brain. The one prevalent failing of the medical art is to neglect the causes and quarrel with the effect.

There are certain general facts which include a good deal of what is called and treated as disease. Thus, there are two opposite movements of life to be seen in cities and elsewhere, belonging to races which, from various persistent causes, are breeding down and tending to run out, and to races which are breeding up, or accumulating vital capital,--a descending and an ascending series. Let me give an example of each; and that I may incidentally remove a common impression about this country as compared with the Old World, an impression which got tipsy with conceit and staggered into the attitude of a formal proposition in the work of Dr. Robert Knox, I will illustrate the downward movement from English experience, and the upward movement from a family history belonging to this immediate neighborhood.

Miss Nightingale speaks of “the fact so often seen of a great-grandmother, who was a tower of physical vigor, descending into a grandmother perhaps a little less vigorous, but still sound as a bell, and healthy to the core, into a mother languid and confined to her carriage and house; and lastly into a daughter sickly and confined to her bed.” So much for the descending English series; now for the ascending American series.

Something more than one hundred and thirty years ago there graduated at Harvard College a delicate youth, who lived an invalid life and died at the age of about fifty. His two children were both of moderate physical power, and one of them diminutive in stature. The next generation rose in physical development, and reached eighty years of age and more in some of its members. The fourth generation was of fair average endowment. The fifth generation, great-great-grandchildren of the slender invalid, are several of, them of extraordinary bodily and mental power; large in stature, formidable alike with their brains and their arms, organized on a more extensive scale than either of their parents.

This brief account illustrates incidentally the fallacy of the universal-degeneration theory applied to American life; the same on which one of our countrymen has lately brought some very forcible facts to bear in a muscular discussion of which we have heard rather more than is good for us. But the two series, American and English, ascending and descending, were adduced with the main purpose of showing the immense difference of vital endowments in different strains of blood; a difference to which all ordinary medication is in all probability a matter of comparatively trivial purport. Many affections which art has to strive against might be easily shown to be vital to the well-being of society. Hydrocephalus, tabes mesenterica, and other similar maladies, are natural agencies which cut off the children of races that are sinking below the decent minimum which nature has established as the condition of viability, before they reach the age of reproduction. They are really not so much diseases, as manifestations of congenital incapacity for life; the race would be ruined if art could ever learn always to preserve the individuals subject to them. We must do the best we can for them, but we ought also to know what these “diseases” mean.

Again, invalidism is the normal state of many organizations. It can be changed to disease, but never to absolute health by medicinal appliances. There are many ladies, ancient and recent, who are perpetually taking remedies for irremediable pains and aches. They ought to have headaches and back-aches and stomach-aches; they are not well if they do not have them. To expect them to live without frequent twinges is like expecting a doctor's old chaise to go without creaking; if it did, we might be sure the springs were broken. There is no doubt that the constant demand for medicinal remedies from patients of this class leads to their over-use; often in the case of cathartics, sometimes in that of opiates. I have been told by an intelligent practitioner in a Western town, that the constant prescription of opiates by certain physicians in his vicinity has rendered the habitual use of that drug in all that region very prevalent; more common, I should think, than alcoholic drunkenness in the most intemperate localities of which I have known anything. A frightful endemic demoralization betrays itself in the frequency with which the haggard features and drooping shoulders of the opium-drunkards are met with in the streets.

The next proposition I would ask you to consider is this: The presumption always is that every noxious agent, including medicines proper, which hurts a well man, hurts a sick one. [Note B.]

Let me illustrate this proposition before you decide upon it. If it were known that a prize-fighter were to have a drastic purgative administered two or three days before a contest, or a large blister applied to his back, no one will question that it would affect the betting on his side unfavorably; we will say to the amount of five per cent. Now the drain upon the resources of the system produced in such a case must be at its minimum, for the subject is a powerful man, in the prime of life, and in admirable condition. If the drug or the blister takes five per cent. from his force of resistance, it will take at least as large a fraction from any invalid. But this invalid has to fight a champion who strikes hard but cannot be hit in return, who will press him sharply for breath, but will never pant himself while the wind can whistle through his fleshless ribs. The suffering combatant is liable to want all his stamina, and five per cent. may lose him the battle.

All noxious agents, all appliances which are not natural food or stimuli, all medicines proper, cost a patient, on the average, five per cent. of his vital force, let us say. Twenty times as much waste of force produced by any of them, that is, would exactly kill him, nothing less than kill him, and nothing more. If this, or something like this, is true, then all these medications are, prima facie, injurious.

In the game of Life-or-Death, Rouge et Noir, as played between the Doctor and the Sexton, this five per cent., this certain small injury entering into the chances is clearly the sexton's perquisite for keeping the green table, over which the game is played, and where he hoards up his gains. Suppose a blister to diminish a man's pain, effusion or dyspnoea to the saving of twenty per cent. in vital force; his profit from it is fifteen, in that case, for it always hurts him five to begin with, according to our previous assumption.

Presumptions are of vast importance in medicine, as in law. A man is presumed innocent until he is proved guilty. A medicine--that is, a noxious agent, like a blister, a seton, an emetic, or a cathartic --should always be presumed to be hurtful. It always is directly hurtful; it may sometimes be indirectly beneficial. If this presumption were established, and disease always assumed to be the innocent victim of circumstances, and not punishable by medicines, that is, noxious agents, or poisons, until the contrary was shown, we should not so frequently hear the remark commonly, perhaps erroneously, attributed to Sir Astley Cooper, but often repeated by sensible persons, that, on the whole, more harm than good is done by medication. Throw out opium, which the Creator himself seems to prescribe, for we often see the scarlet poppy growing in the cornfields, as if it were foreseen that wherever there is hunger to be fed there must also be pain to be soothed; throw out a few specifics which our art did not discover, and is hardly needed to apply [ Note C.]; throw out wine, which is a food, and the vapors which produce the miracle of anaesthesia, and I firmly believe that if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind,--and all the worse for the fishes.

But to justify this proposition, I must add that the injuries inflicted by over-medication are to a great extent masked by disease. Dr. Hooker believes that the typhus syncopatia of a preceding generation in New England “was often in fact a brandy and opium disease.” How is a physician to distinguish the irritation produced by his blister from that caused by the inflammation it was meant to cure? How can he tell the exhaustion produced by his evacuants from the collapse belonging to the disease they were meant to remove?

Lastly, medication without insuring favorable hygienic conditions is like amputation without ligatures. I had a chance to learn this well of old, when physician to the Broad Street district of the Boston Dispensary. There, there was no help for the utter want of wholesome conditions, and if anybody got well under my care, it must have been in virtue of the rough-and-tumble constitution which emerges from the struggle for life in the street gutters, rather than by the aid of my prescriptions.

But if the materia medica were lost overboard, how much more pains would be taken in ordering all the circumstances surrounding the patient (as can be done everywhere out of the crowded pauper districts), than are taken now by too many who think they do their duty and earn their money when they write a recipe for a patient left in an atmosphere of domestic malaria, or to the most negligent kind of nursing! I confess that I should think my chance of recovery from illness less with Hippocrates for my physician and Mrs. Gamp for my nurse, than if I were in the hands of Hahnemann himself, with Florence Nightingale or good Rebecca Taylor to care for me.

If I am right in maintaining that the presumption is always against the use of noxious agents in disease, and if any whom I might influence should adopt this as a principle of practice, they will often find themselves embarrassed by the imperative demand of patients and their friends for such agents where a case is not made out against this standing presumption. I must be permitted to say, that I think the French, a not wholly uncivilized people, are in advance of the English and ourselves in the art of prescribing for the sick without hurting them. And I do confess that I think their varied ptisans and syrups are as much preferable to the mineral regimen of bug-poison and ratsbane, so long in favor on the other side of the Channel, as their art of preparing food for the table to the rude cookery of those hard-feeding and much-dosing islanders. We want a reorganized cuisine of invalidism perhaps as much as the culinary, reform, for which our lyceum lecturers, and others who live much at hotels and taverns, are so urgent. Will you think I am disrespectful if I ask whether, even in Massachusetts, a dose of calomel is not sometimes given by a physician on the same principle as that upon which a landlord occasionally prescribes bacon and eggs,--because he cannot think of anything else quite so handy? I leave my suggestion of borrowing a hint from French practice to your mature consideration.

I may, however, call your attention, briefly, to the singular fact, that English and American practitioners are apt to accuse French medical practice of inertness, and French surgical practice of unnecessary activity. Thus, Dr. Bostock considers French medical treatment, with certain exceptions, as “decidedly less effective” than that of his own country. Mr. S. Cooper, again, defends the simple British practice of procuring union by the first intention against the attacks of M. Roux and Baron Larrey. [Cooper's Surg. Diet. art. “Wounds.” Yet Mr. John Bell gives the French surgeons credit for introducing this doctrine of adhesion, and accuses O'Halloran of “rudeness and ignorance,” and “bold, uncivil language,” in disputing their teaching. Princ. of Surgery, vol. i. p. 42. Mr. Hunter succeeded at last in naturalizing the doctrine and practice, but even he had to struggle against the perpetual jealousy of rivals, and died at length assassinated by an insult.] We have often heard similar opinions maintained by our own countrymen. While Anglo-American criticism blows hot or cold on the two departments of French practice, it is not, I hope, indecent to question whether all the wisdom is necessarily with us in both cases.

Our art has had two or three lessons which have a deep meaning to those who are willing to read them honestly. The use of water-dressings in surgery completed the series of reforms by which was abolished the “coarse and cruel practice” of the older surgeons, who with their dressings and acrid balsams, their tents and leaden tubes, “absolutely delayed the cure.” The doctrine of Broussais, transient as was its empire, reversed the practice of half of Christendom for a season, and taught its hasty disciples to shun their old favorite remedies as mortal poisons. This was not enough permanently to shift the presumption about drugs where it belonged, and so at last, just as the sympathetic powder and the Unguentum Armarium came in a superstitious age to kill out the abuses of external over-medication, the solemn farce of Homoeopathy was enacted in the face of our own too credulous civilization, that under shelter of its pretences the “inward bruises” of over-drugged viscera might be allowed to heal by the first intention. Its lesson we must accept, whether we will or not; its follies we are tired of talking about. The security of the medical profession against this and all similar fancies is in the average constitution of the human mind with regard to the laws of evidence.

My friends and brothers in Art! There is nothing to be feared from the utterance of any seeming heresy to which you may have listened. I cannot compromise your collective wisdom. If I have strained the truth one hair's breadth for the sake of an epigram or an antithesis, you are accustomed to count the normal pulse-beats of sound judgment, and know full well how to recognize the fever-throbs of conceit and the nervous palpitations of rhetoric.

The freedom with which each of us speaks his thought in this presence, belongs in part to the assured position of the Profession in our Commonwealth, to the attitude of Science, which is always fearless, and to the genius of the soil on which we stand, from which Nature withheld the fatal gift of malaria only to fill it with exhalations that breed the fever of inquiry in our blood and in our brain. But mainly we owe the large license of speech we enjoy to those influences and privileges common to us all as self-governing Americans.

This Republic is the chosen home of minorities, of the less power in the presence of the greater. It is a common error to speak of our distinction as consisting in the rule of the majority. Majorities, the greater material powers, have always ruled before. The history of most countries has been that of majorities, mounted majorities, clad in iron, armed with death treading down the tenfold more numerous minorities. In the old civilizations they root themselves like oaks in the soil; men must live in their shadow or cut them down. With us the majority is only the flower of the passing noon, and the minority is the bud which may open in the next morning's sun. We must be tolerant, for the thought which stammers on a single tongue today may organize itself in the growing consciousness of the time, and come back to us like the voice of the multitudinous waves of the ocean on the morrow.

Twenty-five years have passed since one of your honored Presidents spoke to this Society of certain limitations to the power of our Art, now very generally conceded. Some were troubled, some were almost angry, thinking the Profession might suffer from such concessions. It has certainly not suffered here; if, as some affirm, it has lost respect anywhere, it was probably for other, and no doubt sufficient reasons.

Since that time the civilization of this planet has changed hands. Strike out of existence at this moment every person who was breathing on that day, May 27, 1835, and every institution of society, every art and every science would remain intact and complete in the living that would be left. Every idea the world then held has been since dissolved and recrystallized.

We are repeating the same process. Not to make silver shrines for our old divinities, even though by this craft we should have our wealth, was this Society organized and carried on by the good men and true who went before us. Not for this, but to melt the gold out of the past, though its dross should fly in dust to all the winds of heaven, to save all our old treasures of knowledge and mine deeply for new, to cultivate that mutual respect of which outward courtesy is the sign, to work together, to feel together, to take counsel together, and to stand together for the truth, now, always, here, everywhere; for this our fathers instituted, and we accept, the offices and duties of this time-honored Society.

BORDER LINES OF KNOWLEDGE IN SOME PROVINCES OF MEDICAL SCIENCE.

An Introductory Lecture delivered before the Medical Class of Harvard University, November 6, 1861.

[This Lecture appears as it would have been delivered had the time allowed been less strictly, limited. Passages necessarily omitted have been restored, and points briefly touched have been more fully considered. A few notes have been added for the benefit of that limited class of students who care to track an author through the highways and by-ways of his reading. I owe my thanks to several of my professional brethren who have communicated with me on subjects with which they are familiar; especially to Dr. John Dean, for the opportunity of profiting by his unpublished labors, and to Dr. Hasket Derby, for information and references to recent authorities relating to the anatomy and physiology of the eye.]

The entrance upon a new course of Lectures is always a period of interest to instructors and pupils. As the birth of a child to a parent, so is the advent of a new class to a teacher. As the light of the untried world to the infant, so is the dawning of the light resting over the unexplored realms of science to the student. In the name of the Faculty I welcome you, Gentlemen of the Medical Class, new-born babes of science, or lustier nurslings, to this morning of your medical life, and to the arms and the bosom of this ancient University. Fourteen years ago I stood in this place for the first time to address those who occupied these benches. As I recall these past seasons of our joint labors, I feel that they have been on the whole prosperous, and not undeserving of their prosperity.

For it has been my privilege to be associated with a body of true and faithful workers; I cannot praise them freely to their faces, or I should be proud to discourse of the harmonious diligence and the noble spirit in which they have toiled together, not merely to teach their several branches, but to elevate the whole standard of teaching.

I may speak with less restraint of those gentlemen who have aided me in the most laborious part of my daily duties, the Demonstrators, to whom the successive classes have owed so much of their instruction. They rise before me, the dead and the living, in the midst of the most grateful recollections. The fair, manly face and stately figure of my friend, Dr. Samuel Parkman, himself fit for the highest offices of teaching, yet willing to be my faithful assistant in the time of need, come back to me with the long sigh of regret for his early loss to our earthly companionship. Every year I speak the eulogy of Dr. Ainsworth's patient toil as I show his elaborate preparations: When I take down my “American Cyclopaedia” and borrow instruction from the learned articles of Dr. Kneeland, I cease to regret that his indefatigable and intelligent industry was turned into a broader channel. And what can I say too cordial of my long associated companion and friend, Dr. Hodges, whose admirable skill, working through the swiftest and surest fingers that ever held a scalpel among us, has delighted class after class, and filled our Museum with monuments which will convey his name to unborn generations?

This day belongs, however, not to myself and my recollections, but to all of us who teach and all of you who listen, whether experts in our specialties or aliens to their mysteries, or timid neophytes just entering the portals of the hall of science. Look in with me, then, while I attempt to throw some rays into its interior, which shall illuminate a few of its pillars and cornices, and show at the same time how many niches and alcoves remain in darkness.

SCIENCE is the topography of ignorance. From a few elevated points we triangulate vast spaces, inclosing infinite unknown details. We cast the lead, and draw up a little sand from abysses we may never reach with our dredges.